Contract negotiations are about to begin for health insurance companies that want to sell plans next year through the state marketplace, Covered California. One area of scrutiny by the agency is sure to be adequacy of provider networks offered by insurers.

“Insurers have gotten the message that there’s some consumer dissatisfaction out there.”

Last year, in order to keep premium costs down, insurance companies sold plans with a narrowed list of doctors for customers to choose from. The goal was to offer doctors and other providers more patients in exchange for a lower cost of providing services.

But many more people signed up for Covered California plans than had been anticipated, leaving perhaps too few doctors to see the patients. Many people scrambled to find a doctor. Complaints to the state show that some people were forced to leave a trusted specialist; some women in their third trimester of pregnancy found they’d have to switch to an unknown obstetrician for their birth.

“It’s unfair and unrealistic,” said Betsy Imholz, an advocate with Consumers’ Union.She says Alameda County was a hotspot for problems. Some plans forbid people who live in Oakland from seeing doctors across the bridge in San Francisco. And plans did a poor job of pointing this out to consumers before they signed on. “It’s too rigid, and it’s so far from consumers’ expectations and experience,” she said.

Covered California will be negotiating next year’s contracts with insurers over the next several weeks, and health advocates are urging officials to bargain hard on behalf of consumers to expand networks.

At Covered California’s monthly board of directors meeting on Thursday, executive director Peter Lee said the agency was already helping to resolve complaints — including many of the women told they had to change obstetricians. The agency has also asked insurers to expand their networks of doctors.

“We’re doing very active monitoring and in particular in coordination with the Department of Managed Health Care to investigate and assure that plans’ networks are adequate,” he said.

Lee said the three top insurers in the state responded to Covered California’s call to add doctors to their rolls: Anthem, Blue Shield, and Health Net “have done significant work in the last quarter to expand networks,” Lee said.

Anthem said it has added 3,800 doctors to its network since January. Health Net said it has increased its network by 64 percent.

Still, an insurance industry group cautioned the agency not to go too far.

Lee said that 200 complaints were filed to the Department of Managed Health Care over access to care since January, but acknowledged that the number likely didn’t capture the full extent of problems.

“Most people don’t have the sophistication or the wherewithal to know how to complain to a state agency,” Imholz said. “There may be more people out there who have problems who didn’t file a complaint.”

Brett Johnson, associate director of the California Medical Association’s Center for Medical and Regulatory Policy pointed to Covered California’s own statistics presented at last month’s board meeting indicating the agency was dealing with 40 to 50 access issues every day. His group did a survey of physicians and found 55 percent of them said they had difficulty finding in-network specialists to refer their patients to, particularly in fields like cardiology, oncology, nephrology, and other specialties that treat people with chronic conditions.

“A lot of physicians still don’t know if they’re in or out of these networks,” Johnson added. “Part of that confusion is because, for certain products in California all insurance companies have to do is mail a notice to the doctor, and if they don’t hear back from you, it becomes part of your contract.”

Imholz cautioned that the expanded provider networks may not solve the problem of patients who can’t find doctors.

“We need to dig deeper and find out, are they adding generically, are they adding them in places where we’ve been seeing the problems, are they adding them in all products?” she said. “But insurers have gotten the message that there’s some consumer dissatisfaction out there.”

No matter how the insurance companies want to frame it (“Maintain affordability”, “Assure value”, etc.) narrow networks are designed for cherry-picking and cost-shifting (to the patient), Patients with chronic illnesses already have their personal physicians. If they are forced into narrow networks and don’t want to lose continuity of their medical care they have the choice of going out of network or not joining. In either the insurance company wins by avoiding the more expensive care. That’s cherry-picking, and the insurance companies are experts at this. The cost-shifting occurs, of course, when the patient goes out of network either intentionally or accidentally when their visit to an in-network clinic or hospital generates out-of-pocket expenses from providers who aren’t in the network, e.g., anesthesiologists, pathologists, radiologists, hospitalists, physical therapists, etc. See http://blog.hc-disconnects.com/2013/09/24/narrow-networks–less-choice-more-cost-shifting.aspx

Author

April Dembosky

April Dembosky is the health reporter for The California Report and KQED News. She covers health policy and public health, and has reported extensively on the economics of health care, the roll-out of the Affordable Care Act in California, mental health and end-of-life issues.

Her work is regularly rebroadcast on NPR and has been recognized with awards from the Society for Professional Journalists (for sports reporting), and the Association of Health Care Journalists (for a story about pediatric hospice). Her hour-long radio documentary about home funerals won the Best New Artist award from the Third Coast International Audio Festival in 2009.

April occasionally moonlights on the arts beat, covering music and dance. Her story about the first symphony orchestra at Burning Man won the award for Best Use of Sound from the Public Radio News Directors Inc.

Before joining KQED in 2013, April covered technology and Silicon Valley for The Financial Times, and freelanced for Marketplace and The New York Times. She is a graduate of the University of California at Berkeley Graduate School of Journalism and Smith College.

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California faces health care challenges seen across the country. At a time of intense focus on reform, "State of Health" explores these issues and more, bringing you stories of challenge and change in the Golden State. The blog is edited by Carrie Feibel.